Phase I

Phase I of NCIME-development, saw the creation of working groups based on six domains of Indigenous medical education made up of leading medical educators, researchers, scholars, frontline workers, and community organizations. These diverse subject matter expert groups led the development of knowledge products to inform and transform medical education to an inclusive, safe, distinctions based, anti-racist and anti-oppressive model of education.

The 2020-2024 Report on the National Consortium for Indigenous Medical Education: Advancing Indigenous Medical Education

NCIME Phase I

The NCIME Working Groups

In the first phase, the NCIME developed recommendations and improvements through six Working Groups. These groups were Chaired by members of the NCIME Executive Committee and included an Associate Chair who was a resident or early-career physician, and an Elder or Knowledge Keeper. The NCIME staff provided administrative, research and evaluation support, and consultants were utilized as needed for special areas of expertise.

The NCIME Working Groups will continue to provide leadership and support to partners to address areas of common priority as they fulfil their collective responsibilities. The Working Groups will transform Indigenous medical education and contribute to the delivery of culturally safe health care. Each Working Group was led by an NCIME Executive Committee member, aligning areas of expertise with the six priority areas:

Assessment of Indigenous Studies, Cultural Safety, and Anti-racism
Anti-racism, Policies, Processes, and Implementation Support
Indigenous Student Admissions and Transitions
Indigenous Faculty Recruitment and Retention
Improving Cultural Safety in Curriculum
Indigenous Physician Wellness and Joy in Work

The full library of resources produced can be viewed at: NCIME Catalogue – National Consortium for Indigenous Medical Education.

Admissions and Transitions: The Indigenous Student Admissions and Transitions working group has developed a toolkit with a comprehensive list of recommendations to address the chronic underrepresentation of Indigenous medical doctors in Canada, with the goal of increasing this Indigenous representation to parity (approximately 10%). The second toolkit developed by the Admissions and Transitions working group provides a data reporting framework to track pre- admissions and national data that will provide necessary information to determine the successes and limitations of Indigenous student interest, recruitment, and retention into medical programs.

Anti-racism: The Anti-racism, Policies, Processes, and Implementation Support working group has developed a core document that outlines necessary elements for the development of anti-racism policies and processes that specifically address anti-Indigenous racism in medical schools and health care environments. In addition, the anti-racism working group has also developed an implementation guide that provides guidance for the development and implementation of anti- racism policy at the institutional and organizational levels and an anti-racism course module that provides requisite training on understanding specific manifestations of medical colonialism in Canada and how to address them.

Assessment: The Assessment of Indigenous Studies, Cultural Safety and Anti-racism working group has developed an assessment guideline, sample exam toolkit, and implementation guide for medical educators, institutions, and organizations that draws on the experiences and expertise of Indigenous academics, medical educators, and community members. The appropriate assessment tool and training of assessors inclusive of Indigenous ways of knowing, being and doing is fundamental for systemic change in medical education and a formidable means of decreasing instances of racism in the learning and care environments.

Faculty Recruitment and Retention: The Indigenous Faculty Recruitment and Retention working group has developed a leadership program to prioritize the recruitment of Indigenous faculty members by providing necessary training and leadership development to advance mid-career Indigenous physicians into leadership positions. This program is intended to close the gap in low retention rates of Indigenous faculty within academic medicine and prevent burnout among existing Indigenous faculty members working in medical schools. To complement this, the Recruitment and Retention working group has designed an Indigenous physician, academics, and health professionals/educators database to identify Indigenous physicians, academics, health professionals, and educators that have an interest in medical education. This database will help identify Indigenous professionals working in the areas of public health, academic medicine, and health care and reduce repetition of work.

Curriculum: The Improving Cultural Safety in Curriculum working group has provided updates to the First Nations, Inuit, and Métis Health Core Competencies: A Curriculum Framework for Undergraduate Medical Education report and made additional recommendations. This work was based on a cultural safety, anti-racism and graduating outcomes gaps in medical education frameworks report.

Joy and Wellness: The Indigenous physicians wellness and joy in work working group sought to define, through a consensus of Indigenous physicians, what wellness and joy in work look like. From this feedback, the wellness and joy in work working group has developed a framework, a faculty development forum that offers supportive space for Indigenous faculty to gather, provide skills development and mentorship opportunities, and help fellow Indigenous physicians navigate academic careers.

Shared Themes

Throughout the NCIME working group documents there are several shared themes that consistently emerge which include:

Indigenous representation in medical schools.
Addressing health disparities experienced by Indigenous patients.
Enhancing or developing cultural safety practices in medical schools.
Collaboration and engagement with Indigenous communities and organizations.
Allocating resources and funding to support the implementation of recommendations.
Training and capacity building for admissions and transition teams, faculty, and healthcare professionals.
Evaluation and monitoring processes to ensure ongoing alignment with recommendations.
Addressing anti-Indigenous racism at institutional and organizational levels by developing or refining existing policy.
Incorporating Indigenous perspectives and content into medical education curriculum.
Supporting the recruitment, retention, and leadership development of Indigenous faculty and healthcare professionals.
Creating safe and supportive environments for Indigenous students, faculty, physicians and promoting their wellness and joy in work.

Recommendations

Admissions and Transitions: The Admissions and transitions working group recommendations are intended to support medical schools in increasing the number of Indigenous students in medical schools to 10% in the next decade. Further, the Admissions and transitions working group has outlined the need for enhanced cultural safety practices in medical schools that will have benefits towards addressing health disparities experienced by Indigenous patients and improving access to health services for Indigenous patients. The key recommendations include:

Conduct an institutional readiness survey to assess existing mechanisms for accountability and identify required structural supports.
Consider strategic alignment between the institutional strategic plan and admissions and transition recommendations.
Review the budget and allocate resources to address and plan for the adoption of NCIME recommendations.
Establish governance structures, including team roles and responsibilities, decision-making processes, and communication plans.
Assess existing technology systems and infrastructure to support admissions data-related recommendations.
Inventory existing admissions and transitions practices and make inclusions and exclusions based on NCIME recommendations.
Provide training and capacity building programs for admissions and transition teams.
Prioritize relationship-building with Indigenous communities, including co-creation of policies and procedures and Indigenous community input in decision-making.
Promote culturally informed protocols in admissions and transition processes.
Support the learner experiences of Indigenous medical students, residents, and practicing medical professionals through academic support systems, cultural integration, mentorship programs, and continuing education opportunities.
Implement iterative monitoring and evaluation processes to ensure ongoing alignment with NCIME recommendations and gather feedback for adaptation and improvement.

Anti-racism: The recommendations put forth by the Anti-racism working group are intended to provide guidance for the development of anti-racism policy that meaningfully addresses anti- Indigenous racism at the institutional (medical schools) and organizational (medical assessment and evaluating organizations) levels. The objective of the Anti-racism working group deliverables is to provide a roadmap for the development of anti-racism policy that is attendant to anti-Indigenous racism. The following ten recommendations for the development of anti-racism policy have emerged from the Anti-racism working group documents:

Engage with Indigenous communities and organizations: It is important to collaborate with Indigenous communities and organizations to ensure that the policy is culturally safe and addresses the specific needs and concerns of Indigenous
Seek buy-in from senior leadership and all levels of the institution/organization: Commitment from stakeholders at all levels is crucial for the effective implementation of anti-racism This includes publishing public statements, resolutions, strategies, and incorporating anti-racism policy, principles, and practices.
Identify current anti-racism policies and their effectiveness in addressing anti-Indigenous racism: Assess the existing anti-racism policies and determine if they adequately address anti-Indigenous If a policy exists, identify the changes needed to align it with the needs of Indigenous peoples.
Allocate funds, resources, and capacity: Provide the necessary resources and support to begin and sustain the relationship building and policy development/amendment
Develop a comprehensive resourcing plan: Ensure that there are adequate supports for the development and implementation stages of policy
Promote, advance, and hire experts: Identify and hire individuals with cultural, community- based, traditional knowledge, and lived experience relevant to the role. This can include Indigenous faculty members, community authorities, and existing Indigenous administrative
Establish evaluation processes: Develop processes to evaluate the effectiveness of the new anti- racism policy. This should include regular reporting, data collection, and analysis in collaboration with Indigenous
Provide training and education: Develop a comprehensive training plan for all members of the institution/organization to ensure that they have the necessary knowledge and skills to address anti-Indigenous
Establish reporting mechanisms: Create secure and confidential reporting mechanisms to track policy use and Ensure that there are clear procedures for addressing grievances and conflicts related to anti-Indigenous racism.
Sustain and continue change: Develop processes and supports to sustain and continue the implementation of the anti-racism policy. This includes establishing standardized competencies and training requirements, providing culturally safe supports for Indigenous peoples, and implementing ongoing evaluation and quality improvement

Assessment: The recommendations developed by the Assessment working group are intended to provide guidance and support for medical schools and medical education organizations to address anti-Indigenous racism in medical learner assessments, training, and health care broadly. The Assessment working group has provided clear and actionable steps to re-evaluate and reform assessment tools used throughout undergraduate medical education (UGME) and postgraduate level medical education (PGME). The following ten recommendations put forth by the Assessment working group will help medical schools and medical education organizations develop culturally safe, and anti-racist learner assessments:

Identify expertise and resources needed for the assessment, involving Indigenous and non-Indigenous experts.
Establish an Indigenous Assessment Committee (IAC) with Indigenous community members and patients to lead the development and implementation processes.
Host workshops on best practices in assessment development, including Indigenous learners.
Integrate Indigenous health content throughout the curriculum and map exam points with Indigenous health content sessions.
Decide on the types of assessments to use and develop clear rubrics with learning objectives.
Host brainstorming sessions with the IAC and relevant partners to develop question stems for multiple assessment types.
Consider forming working groups with equal representation of Indigenous experts, Elders, community representatives, and clinicians to develop multiple assessment formats.
Review proposed questions for adherence to guidelines and best practices, incorporating cultural humility and reflection for non-Indigenous partners.
Recruit and train Indigenous Standardized Patients (SPs) and assessors for the proposed questions, avoiding the use of non-Indigenous SPs for Indigenous examinations.
Ensure assessors and trainers are trained and proficient in recognizing the key aspects of cultural safety.
Other recommendations include standardization of case examples, collaboration with Indigenous collaborators, following medical school protocols, providing supports for Indigenous learners, conducting debriefing sessions, involving Indigenous SPs in providing feedback, utilizing Quality Improvement (QI) approaches, involving Indigenous partners in data analysis, incorporating decolonizing and anti-colonial approaches, collaborating with Indigenous peoples in writing assessments, measuring success through Indigenous satisfaction, conducting formative and progress evaluations, developing Indigenous-specific evaluation frameworks, balancing Indigenous cultural perspectives with western processes, hiring local Indigenous experts as evaluators, respecting Indigenous sovereignty, and giving Indigenous communities a voice in decisions regarding their health and well-being.

Faculty recruitment and retention: The Faculty recruitment and retention working group has advanced a series of recommendations that are intended to support hiring, retention, and leadership development of Indigenous faculty, physicians, health professionals, and educators interested in contributing to Indigenous medical education at medical schools across Canada.

The key recommendations put forth by the faculty recruitment and retention working group include:
Implement the Early to Mid-Career Indigenous Physician Leadership Development Program to address gaps and provide mentorship for emerging Indigenous leaders in academic medicine.
Establish a long-term, sustainable funding source for the program.
Each medical school should select and sponsor an early career physician yearly to participate in the program.
Create a selection committee at each medical school to choose the successful candidate based on specific criteria.
Develop a communications plan to inform potential applicants about the program.
Hire an evaluation specialist to ensure the program meets the needs of the trainees and evaluate its success.
Create internal changes at an institutional level and external programs and policies to support the recruitment and retention of Indigenous medical faculty.
Engage in the creation or review of strategic plans at medical schools to include Indigenous initiatives and align with relevant guidelines and recommendations.
Enact policies to support the recruitment and retention of Indigenous physicians, including creating programming, products, policies, and events.
Include cultural events and ceremonies as Continuing Medical Education (CME) units for Indigenous physicians and faculty.
Create an allyship program for non-Indigenous faculty to support emerging Indigenous faculty.
Organize an annual meeting for Indigenous Academic Medical Deans to discuss priorities and approaches.
Update benchmarks for each medical school to meet recommendations from various commissions and inquiries.
Develop a leadership program for all Indigenous staff, including those in support roles.
Establish an endowment fund to support early-career Indigenous medical faculty pursuing leadership training.
Mandate a minimum allocation of 5% of each medical school’s budget to Indigenous initiatives as part of the accreditation process.

Curriculum: The recommendations developed by the Curriculum working group are intended to ensure Indigenous health curriculum in medical education includes up to date, and important cultural, social, political perspectives to help train future and existing healthcare professionals in Canada. The Curriculum working group emphasizes the inclusion of diverse Indigenous perspectives, Indigenous studies, anti-racism, ethical community engagement protocols and processes, and experiential learning experiences. The key recommendations from the Curriculum working group follow the CanMEDs roles and include:

Medical Expert:

Understanding the historical and current government practices that impact Indigenous peoples.
Establishing patient-defined goals and collaborating with family and community in the care plan.
Describing the various health and social services delivered to Indigenous peoples and understanding the multi-jurisdictional influences on healthcare resources and delivery.
Identifying the diversity among Indigenous communities and understanding their various histories, perspectives, attitudes, beliefs, and behaviours.
Articulating how holistic understandings of health for Indigenous peoples are determined by broader determinants of health and well-being.
Identifying and describing the range of healing and wellness practices present in local Indigenous communities.

Communicator:

Understanding and addressing different forms of racism and unconscious bias in healthcare.
Demonstrating cultural humility and delivering culturally safe care.
Recognizing and mitigating power differentials between Indigenous patients and physicians.
Engaging in culturally safe communication with Indigenous patients, families, and communities.
Developing positive and collaborative therapeutic relationships with Indigenous patients and their families.

Collaborator:

Building collaborative and ethical relationships with Indigenous organizations, communities, and healthcare professionals.
Collaborating with Traditional Healers/Medicine People in delivering healthcare.
Appropriately inquiring about and integrating traditional herbs or medicines into patient care.
Allyship with Indigenous populations and communities.

Leader:

Understanding strength-based concepts and principles in Indigenous health care.
Recognizing instances of anti-Indigenous racism and culturally unsafe care and taking appropriate action.
Giving equitable space for Indigenous voices and engaging in collaborative therapeutic dialogue.
Describing successful approaches to improving Indigenous health.

Health Advocate:

Identifying determinants of health and addressing inequities in access to healthcare and health information.
Understanding and implementing policy recommendations and frameworks related to Indigenous health.
Recognizing the impacts of intersectionality on Indigenous health.
Respecting Indigenous ways of knowing, being, and doing.
Understand the importance of trust, accountability, and relationship building.

Scholar:

Collaborating with Indigenous populations in research and respecting ethics protocols.
Understanding the differences between Indigenous and Western research paradigms.
Sharing and promoting health information with Indigenous patients and populations.
Applying community-based data and research policies and protocols.
Critically appraising available data on Indigenous health.

Professional:

Acknowledging and analyzing personal emotional responses to Indigenous histories and contemporary issues.
Recognizing and addressing existing forms of racism and biases.
Engaging in reflective practice and cultural humility.
Participating in peer accountability and fostering safe clinical and learning environments.
These enabling competencies provide a comprehensive framework for the development of knowledge, skills, and attitudes necessary for medical learners to provide culturally safe and effective care to Indigenous patients and to contribute to improving Indigenous health outcomes.

Joy and Wellness: To engage with and uplift Indigenous physicians the Indigenous Physician wellness and joy in work working group has put forth a series of recommendations for medical schools, ministries of health, hospital systems, regulatory colleges, and CMPA. These actions include creating a safe and supportive clinical space that allows Indigenous practitioners to express, incorporate, and celebrate their culture. Additionally, it is important for these institutions to recognize the impact of the healthcare ecosystem on Indigenous Peoples who practice medicine, considering their complex intersectionality and movement between different cultural contexts.

Furthermore, guidance and best practices should be shared with communities and Indigenous organizations to invest in the health of Indigenous Peoples who practice medicine. Lastly, it is crucial to acknowledge the burden of minority tax and advocate for equitable pay for the labour, expertise, and unique abilities of Indigenous physicians.

The key recommendations are as follows:

Publish the Calls to Action (CTAs) and Background Paper in a manner that upholds Indigenous OCAP principles, including a modified version suitable for publication in an academic journal.
Create an interactive online resource based on the Physician wellness and joy in work working group (PWJW) emblem, featuring video clips of Indigenous physicians and Elders offering reflections and resources.
Communicate with key partner organizations and clearly outline the CTAs recommended for each organization, providing a roadmap for action.
Develop customized letters for key partner organizations, highlighting the relevant CTAs for them to consider acting upon.
Present the Calls to Action at Indigenous Health, Medical Education, and Physician Health Conferences, using panel presentations and workshops to allow input from multiple Working Group members.
Form a Community of Practice in Phase 2 of NCIME planning to continue the work of the Working Group beyond 2024, serving as a circle of expertise and representative body for engagement.
Fund a review and update on the CTAs in 2026/2027 to monitor and evaluate partner.